International Consensus Statement Combats Obesity Stigma

Miriam E. Tucker

March 06, 2020

An international panel of obesity experts has issued a joint consensus statement calling for an end to the "pervasive, resilient form of social stigma" associated with the disease.

Published online March 4 in Nature Medicine with open access — to coincide with World Obesity Day — the statement is endorsed by over 100 professional societies, including the American Association of Clinical Endocrinologists, American Diabetes Association, Diabetes UK, Obesity Society, American Association for Metabolic and Bariatric Surgery, Endocrine Society, Royal College of Physicians (UK), and many other organizations from around the world.  

Several scientific and medical journals have also agreed to take the "pledge to eliminate weight bias and stigma of obesity" included in the statement, such as the Annals of Surgery, Lancet Diabetes & Endocrinology, all Nature Research journals, Cell Metabolism, and several obesity journals. The pledge attests to the recognition of the social stigma surrounding overweight and obesity and its consequences, to the condemnation of the use of stigmatizing language, images, and policies, and to the practice and encouragement of treating people with overweight and obesity with "dignity and respect."

Lead author Francesco Rubino, MD, professor and chair of bariatric and metabolic surgery at King's College London, UK, told Medscape Medical News that the overarching goal of the statement is to encourage all stakeholders "to think and speak differently about obesity, change the current unscientific narrative based on misconceptions like the assumption that obesity is merely a matter of personal responsibility, that people with obesity are lazy because one could lose weight by merely deciding to do so, or that obesity is entirely reversible, no matter how severe."

Patient care is adversely affected when clinicians hold these assumptions, he said. "It is because of these assumptions that clinicians often think their patients with obesity tend not to follow medical advice, so much so that they end up spending less time with them as evidence shows. Those assumptions also explain why clinicians tend to ignore decades of medical evidence and continue to expect patients to resolve their obesity substantially by themselves instead of referring them for proper and evidence-based therapies."

Obesity expert Amy Rothberg, MD, PhD, an endocrinologist at the University of Michigan, Ann Arbor, told Medscape Medical News the statement is likely to have an impact. "Many of the authors are luminaries in the field, all coming together with the same message. I think it's an important message to convey. There is a stigma associated with overweight and obesity, and even more for women than men. The statement says it's not per volition, that patients deserve to be treated with respect and have access to effective interventions. People should adopt that message."
However, Rothberg faulted the statement for not providing sufficient obesity management guidance for clinicians. "There is stigma, but how can we make that better? What is the action plan around that? Many of our interventions will result in decreased weight, but without long-term follow-up, patients may have problems maintaining their reduced weight, so it's a critical need and gap. Clinicians need better chronic care resources, and patients need better coverage from insurance companies for obesity management."

Statement Condemns Negative Attitudes, Reinforces Obesity as a "Disease"

The document includes a list of statements about weight-based stigma in 11 domains: overall prevalence, the media, healthcare, schools and workplaces, physical and mental health consequences, quality of and access to care, public health, research, causes/contributors, science versus misconceptions, and the issue of obesity as a "condition" versus a "disease."

With respect to healthcare, the consensus statement warns against "negative attitudes about obesity, including stereotypes that affected patients are lazy, lack self-control and willpower, are personally to blame for their weight, and are noncompliant with treatment." It is unacceptable for healthcare professionals, especially those whose specialty is patients with obesity, to hold a weight-based stigma, the authors explain, adding that many healthcare facilities are not adequately prepared to care for patients with obesity.

And on the "condition" versus "disease" question:

  1. There is objective evidence that in many patients obesity presents the typical attributes of a disease status, which include specific signs and/or symptoms, distinct pathophysiology, reduced quality of life, and increased risk for complications/mortality.

  2. Although prevailing evidence supports a rationale for obesity to be defined as a disease, as recognized by leading worldwide authority bodies and medical associations, current diagnostic criteria for obesity (only based on body mass index levels) are inadequate to accurately diagnose obesity.

Rubino noted, "If you believe the cause of obesity and its current epidemic are already known and substantially amount to individual faults, laziness, and overeating, you do not even start looking for the root cause of the problem."

Recommendations Address Several Sectors, Including Medical Education

The statement provides a list of 13 recommendations, under the headings of generalities, media, healthcare and education of healthcare providers, public health, research, and policies/legislation.

Academic institutions, professional bodies, and regulatory agencies must make sure that standard curricula for medical trainees and other healthcare providers includes formal education "on the causes, mechanisms, and treatments of obesity," according to the consensus statement.

Healthcare providers who specialize in obesity treatment should demonstrate "stigma-free practice skills. Professional bodies should encourage, facilitate, and develop methods to certify knowledge of stigma and its effects, along with stigma-free skills and practices."

The prevalence of obesity and obesity-related diseases is high; therefore, "appropriate infrastructure for the care and management of people with obesity, including severe obesity, must be standard requirement for accreditation of medical facilities and hospitals," the authors explain.

Rothberg said that although she supports the content of the statement, she wishes it had gone further. "Primary care clinicians don't have enough time and resources. How do we teach them to be experts in what we're asking them to do? They see patients every 15 minutes. There are competing priorities that rise above what is probably the root of many of those other problems. I'd like there to be an action plan, particularly for those in the trenches taking care of people with a whole host of diseases related to obesity."

Of course there are evidence-based guidelines from organizations such as the Endocrine Society, National Heart, Lung, and Blood Institute, and American Association of Clinical Endocrinologists but they're not available in a quick, user-friendly format for busy clinicians, Rothberg noted.

Nonetheless, she said, "Overall, I think this consensus statement is good. We don't want people to feel embarrassed or ashamed or judged. People know when they're overweight or obese. We don't need to tell them. We want them to know they can get treatment if they want it."

None of the members of the organizing committee or voting members of the expert panel received payment for their participation. Travel expenses for the face-to-face meeting of the expert panel were supported by Medtronic, Ethicon, Novo Nordisk, Fractyl Laboratories, GI Dynamics, Cairn Diagnostics, Keyron, and Aventic Group. Rubino is on advisory boards for GI Dynamics, Keyron, and Novo Nordisk, and has received consulting fees and research funding from Ethicon Endosurgery and Medtronic. Rothberg is on the advisory board for Rhythm Pharma and receives research support from Nestle. She was on a panel that reviewed the statement for the Endocrine Society for endorsement but had no role in its development.

Nat Med. Published online March 4, 2020. Full text

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